Article Type: Research
Received : September 20, 2018
Accepted : October 04, 2018
Published: October10, 2018
*Correspondence to: Jose Luis Turabian* Specialist in Family and Community Medicine, Health Center Santa Maria de Benquerencia.
Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain. E-mail: firstname.lastname@example.org
Article Type: Research
Received : September 20, 2018
Accepted : October 04, 2018
Published: October10, 2018
The continuity of care allows the general practitioner (GP) to see the phases of high tide and low tide of his patients: "crustaceans, shells and treasures, but also mud, rocks, stranded ships, depressions and cracks of the rocky littorals"; the strengths of the patients but also the problems and conflicts that seemed hidden. When the tide is high, the GP sees the biopsychosocial disease in its most florid, turbulent expression. So, he can see acute diseases: acute bronchitis, bone fractures, asthma attacks, etc. On the other hand, the tides depend on the place. So, individual disease depends on the context. Sometimes, the high tide isolates earth parts, turning them into temporary islands that return to be parts of the coast when lowering the tide. The disease can isolate the patient: from his daily life, from his work, from his family or friends. During low tide we will see the most stable periods of chronic diseases, such as arthritis and osteoarthrosis, diabetes, etc. Thus, when the tide is low the GP has the opportunity to do "opportunistic prevention." But, also, when the tide goes down, the GP can see "garbage bags, soda cans ...": polypharmacy, the adverse drug reactions, overdiagnosis and overtreatment. In conclusion, when there is low tide, get up one day at dawn and go to the edge of the beach, where the sand is wet. There are countless seashells ... it will be a very beautiful experience!
KEYWORDS: Family physician; Family practice; Preventive Medicine; Preventive Care; Health Promotion; Anticipatory Care; Continuity of Patient Care; Natural History of Disease; Physician-Patient Relations.
When the ocean grows we speak of high tide; It is the moment when the waters cover the shores of the coasts. When the sea is frizzy, the bottom sediment is agitated and the water becomes cloudy.
When the tide is low, the wind stops and the mud is deposited in the bottom little by little and the water becomes transparent everything looks very different from when the tide is high. You can catch crustaceans and shells ... without having to dive..., just walking on the wet sand. You see the treasures! That chest full of treasures of the galleon that was shipwrecked centuries ago ... it's left to the naked eye! Without striving!
The low tide exposes living species, and mud, stones ..., but it is also possible to find garbage bags, soda cans, and diverse machinery ... You can see landscapes that reveal moral and ecological conflicts. Many beaches are exposed and many boats are stranded in them. Algae are dragged there by the waves on almost every beach, but live seaweed is only seen on rocky shores at low tide. In low tide, dozens of depressions and cracks are visible. Most of them will be flooded with water, which will vary depending on their size. The organisms that inhabit these areas are grouped in horizontal bands or kept in the puddles formed when the tide is low, everything depends on their adaptation to changes in humidity, salinity, temperature or wave resistance. There will be crustaceans there. We will also find limpets, as well as some mollusc that feeds on those crustaceans. We find algae that cover the rocks, and with them a rich fauna composed of crabs, worms, etc. .
The continuity of care allows the general practitioner (GP) to see the phases of high tide and low tide of his patients (FIGURE 1, FIGURE 2). The GP can see "crustaceans, shells and treasures, but also mud, rocks, stranded ships, depressions and cracks of the rocky littorals "; he can see the strengths of the patients and detect the risk factors, but also the problems and conflicts that seemed hidden. The continuity of attention is considered a defining characteristic of general medicine. However, despite decades of study it remains difficult to define and quantify and can be seen from different disciplines and perspectives [2-7]; maybe the image of high tides and low tides will help us understand it. In any case, continuity of care between the doctor and the patient builds trust and allows the doctor to use more productively the time available, since it facilitates the discovery of problems that are not seen at first sight; allows diagnosis and treatment. The GP that performs continuous care can make "almost magical" diagnoses; when the problem has not yet been defined, the diagnosis already was made: thanks to the continued knowledge of people, problems and contexts.
This continuity of attention of the GP allows the knowledge of the phases of the tides... That is, the knowledge of the natural history of the disease. Natural history of disease refers to the progression of a disease process in an individual over time. Natural history of disease represents the course of biological events between the sequential action of component causes (etiology) until the disease develops and the outcome occurs (healing, passing to chronicity or death). The interest of medicine to know the natural evolution of each disease is to discover the different stages and components of the pathological process, to can intervene as early as possible and change the course of the disease, in order to avoid the deterioration of health.
The process begins with the appropriate exposure to or accumulation of factors sufficient for the disease to begin in a susceptible host. For an infectious disease, the exposure is a microorganism; for cancer, the exposure may be a factor that initiates the process, such as asbestos fibers or components in tobacco smoke (for lung cancer), or one that promotes the process, such as estrogen (for endometrial cancer).
After the disease process has been triggered, pathological changes then occur without the individual being aware of them. This stage of subclinical disease, extending from the time of exposure to onset of disease symptoms, is usually called the incubation period for infectious diseases, and the latency period for chronic diseases. During this stage, disease is said to be asymptomatic or unapparent. This period may be as brief as seconds for hypersensitivity of allergic reactions to as long as decades for certain chronic diseases.
Although disease is not apparent during the incubation period, some pathologic changes may be detectable with laboratory, radiographic, or other screening methods. Most screening programs attempt to identify the disease process during this phase of its natural history, since intervention at this early stage is likely to be more effective than treatment given after the disease has progressed and become symptomatic.
The onset of symptoms marks the transition from subclinical to clinical disease; from the low tide to high tide. Most diagnoses are made during the stage of clinical disease, but we could have prevented, or we could have adapted, or to be now capable more easily of managing the health problem, if we had been attentive in the phase of low tide, before raising the sea level and that the waves are curling and the water becomes cloudy., In some people, however, the disease process may never progress to clinically apparent illness. In others, the disease process may result in illness that ranges from mild to severe or fatal. This range is called the spectrum of disease. Ultimately, the disease process ends either in recovery, cronicity, disability or death.
Some ways of classifying and systematizing the study of the natural history of diseases (something like the classifications of the tables or schedules of the tides) are: Beginning: acute or gradual; Course: progressive, constant, recurrent; Result: fatal or non-fatal; Common disease pattern in children; Diseases which become more prevalent with age; Diseases are "once and always" (that is, once they arise they persist all their lives); Diseases that appear to follow a course and disappear; Diseases whose etiology is understood sufficiently or partially or not well known for prevention or screening .
On the other hand, individual disease depends on the context. The patient is a spokesman for the sick or problematic context (family conflict, social problem). Therefore, symptoms may be forms of expression of biological alterations, or group or family alterations, or symbols or ways of coping with a situation. One of the factors that influence the type of symptoms is the stage of the family life cycle in which the patient is. This perspective considers that biological and psychosocial processes, affect not only the possible risk of disease, but surround or frame the symptoms of the affected persons. For example, when an acute coronary syndrome occurs, different stages of the patient's family life cycle may give rise to different symptoms for each of these stages . Of course: the tides depend on the place; on the European coasts of the Atlantic Ocean they can be very intense; on the shores of the Mediterranean Sea they tend to be less intense or less noticeable.
Ignorance of this evolution can lead to significant errors of judgment on the diagnostic and therapeutic decisions. Knowing the evolutionary trend of the disease, the doctor can foresee success or failure. The knowledge of the repetition of a certain pattern of expression of a symptom in a patient, or variation in the expected pattern, or "the footprint that should not be there" -"Robinson's sign" (as happened to Robinson Crusoe who saw a human footprint on the beach of his island "deserted": how could he be there? It was a mystery), can give us the diagnosis [10, 11].
When the tide is high, the GP sees the biopsychosocial disease in its most florid, turbulent expression. So, we can see acute diseases: acute bronchitis, conjunctivitis, bone fractures, appendicitis and other acute abdomens, gastroenteritis, acute urticaria, asthma attacks, burns, acute myocardial infarction, or more rarely, acute encephalomyelitis, or acute lymphoblastic leukaemia. In addition, it can happen that a chronic disease has periods of exacerbation -of high tide-, and that an acute illness, when was not properly treated, leads to a chronic condition -of low tide. For example, acute pain can progress to chronic pain if the cause that gave rise to it is not adequately treated. Or as in the case of a chronic disease such as asthma, patients usually experience periods of acute crisis that remit under treatment.
Sometimes, the high tide isolates earth parts, turning them into temporary islands that return to be parts of the coast when lowering the tide. The disease can isolate the patient: from his daily life, from his work, from his family or friends. The sick person can be isolated not only by their biological symptoms, but also by their psychosocial effects: stigma, discrimination, loss, fear, anguish, blame, self-punishment, stress, suffering, self-exclusion, shame, dependence, vulnerability ..., and also rejection, changes of habits, prohibitions, loss of dignity, change of role in the family and family dynamics, changes in routines and impossibility of certain tasks, etc. The effects biological (specific) and psychosocial (non-specific) are not simply additive, but interact throughout the natural history of the disease and can be observed in continuous care, with its phases of improvement -low tide-, and worsening - high tide .
During low tide we will see the most stable periods of chronic diseases, such as Alzheimer's disease, Parkinson's disease, arthritis and osteoarthrosis, Amyotrophic Lateral Sclerosis, multiple sclerosis, diabetes, schizophrenia, bipolar disorders, Crohn's disease, bronchial asthma, etc. And on the other hand, the chronic disease develops for many years and its onset is usually insidious, so that it can go unnoticed until the symptoms are evident. For example, people affected by Parkinson's disease suffer from depression, constipation and sleep disturbances many years before the motor symptoms, the best known of the disease, are easily detectable. Something similar happens with Alzheimer, which has decades of evolution before reaching the point of causing dementia, which is its most feared consequence. Before, Alzheimer's could cause more specific manifestations, such as forgetting frequent events or difficulties in finding the right word. Thus, when the tide is low the GP has the opportunity to do "opportunistic prevention", which includes at least anticipatory care and Case-finding .
At low tide, the transparency of the waters allows the GP to see "turning points" or transitions of patients and their contexts. These transitions are related to: a) The life cycle of the individual and the family; b) The sudden loss of stability c) The recurrence of problematic factors; and d) The accumulation of a number of problematic factors . During a transition, people experience stress and anxiety. GP can allow some changes where patients move from one stage to another while he helps to maintain all chances of achieving positive results. From this perspective, addressing the apparent and inapparent problems and obstacles of a transition is part of continued care in family medicine.
But remember that also, when the tide goes down, the GP can see "garbage bags, soda cans ...": when the GP sees the perspective to their interventions on the patients - that is, when he reflects, can see aspects that could be somewhat hidden, such as the polypharmacy, the adverse drug reactions, overdiagnosis and overtreatment ... and he could intervene in these situations, and modify their medical behaviour to avoid repeating such problems .
In conclusion, when there is low tide, get up one day at dawn and go to the edge of the beach, where the sand is wet. There are countless seashells ... it will be a very beautiful experience!
1.Turabian JL, Pérez Franco B (2013) The wise master or the thirty thousand laws of the four seasons (first part). Rev Clín Med Fam; 6(3): 160-8. http://www.redalyc.org/pdf/1696/169630517009.pdf
2.-Schultz K (2009) Strategies to enhance teaching about continuity of care. Can Fam Physician; 55(6): 666-8. http://www.cfp.ca/content/55/6/666.long
3.-Stokes T, Tarrant C, Mainous III AG, Schers H, Freeman G, et.al (2005) Continuity of Care: Is the Personal Doctor Still Important? A Survey of General Practitioners and Family Physicians in England and Wales, the United States, and the Netherlands. Ann Fam Med; 3(4): 353-9. http://www.annfammed.org/content/3/4/353.full
4.-Hill AP, Freeman GK (2011) Continuity of care. Promoting Continuity of Care in General Practice. RCGP Policy Paper. March 2011. The Royal College of General Practitioners. http://www.rcgp.org.uk/policy/rcgp-policy-areas/continuity-of-care.aspx
5.-Cammer A, Morgan D, Stewart N, McGilton K, Rycroft-Malone J, et al. (2014) The Hidden Complexity of Long-Term Care: How Context Mediates Knowledge Translation and Use of Best Practices. Gerontologist; 54(6):1013-23. http://gerontologist.oxfordjournals.org/content/54/6/1013.full
6.-Bentler SE, Morgan RO, Virnig BA, Wolinsky FD (2014) Do Claims-Based Continuity of Care Measures Reflect the Patient Perspective? Med Care Res Rev: 71(2): 156-73. http://mcr.sagepub.com/content/71/2/156?etoc
7.-Turabian JL, Pérez Franco B (2015) Observations, insights and anecdotes from the perspective of the physician, for a theory of the natural history of interpersonal continuity. The colors of time. Rev Clin Med Fam; 8(2): 125-
8.-Turabian JL (2017) A Narrative Review of Natural History of Diseases and Continuity of Care in Family Medicine. Arch Community. Med Public Health 3(1): 041-7. https://www.peertechz.com/articles/a-narrative-review-of-natural-history-of-diseases-and-continuity-of-care-in-family-medicine.pdf
9.-Turabian JL, Báez-Montiel B and Gutiérrez-Islas E (2016) Type of Presentation of Coronary Artery Disease According the Family Life Cycle. SM J Community Med; 2(2): 1019. http://smjournals.com/community-medicine/in-press.php#
10.-Turabian JL (2017) Stories Notebook about the Fundamental Concepts in Family Medicine: Continuity, The Fable of The River with Meanders. J Gen Pract (Los Ángel) 5:285. https://www.esciencecentral.org/journals/stories-notebook-about-the-fundamental-concepts-in-family-medicinecontinuity-the-fable-of-the-river-with-meanders-2329-9126-1000285.php?aid=85622
11.-Turabian JL, Samarín-Ocampos E, Minier L, Pérez-Franco B (2015) Learning concepts of diagnosis in family medicine: the “mark robinson sign” - the traces that should not be there. Aten Primaria; 47(09): 596-602. http://www.elsevier.es/es-revista-atencion-primaria-27-articulo-aprendiendo-conceptos-del-diagnostico-medicina-90443461
12.-Turabian JL, Pérez-Franco B (2014) Journey to what is essentially invisible: Pysochosocial aspects of disease. Semergen; 40:65-72.
13.-Turabian JL (2017) Opportunistic Prevention in Family Medicine: Anticipatory Care, Case-Finding and Continuity of Care. J Health Care Prev 1: 101. https://www.omicsonline.org/open-access/opportunistic-prevention-in-family-medicine-anticipatory-care-casefinding-and-continuity-of-care.pdf
14.-Turabian JL, Franco BP (2016) Turning Points and Transitions in the Health of the Patients: A Perspective from Family Medicine. J Family Med Community Health 3(4): 1087. https://www.jscimedcentral.com/FamilyMedicine/familymedicine-3-1087.pdf
15.-Turabian JL (2018) Ssighing by ticagrelor: inducing theoretical concepts for general medicine from a case study. International Journal of Biopharmaceutical Sciences. In Press. https://www.boffinaccess.com/journals/biopharmaceutical-sciences/ijbs.php